SHOULDER PHYSCICAL EXAMINATION & APPROACH.pptx

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1. SHOULDER PHYSCICAL EXAMINATION & SURGICAL APPROACH

2. PHYSICAL EXAMINATION LOOK FEEL MOVE Special Test : Rotator cuff disease & impingement Instability & Laxity Biceps tendon & SLAP AC & SC joint

3. LOOK Anterior side Posterior side Lateral Overhead Axillary

4. LOOK Anterior Side Deltoid Atrophy  Axillary Nerve Palsy Loss of deltoid contour  Dislocation Bony Prominent

5. LOOK Sub Acromial region Swelling  bursitis Biceps tendon Proximal Rupture  Popeye bulge Distal Rupture  Hook Test/Sign HOOK SIGN/TEST POPEYE BULGE

6. LOOK Posterior side Scapula Position  High  Sprengel’s Shoulder Spine Fossae  supraspinatus & infraspinatus atrophy

7. LOOK Borders of scapula lateral ; prominent in Latisimus dorsi atrophy superior ; prominent in supraspinatus & trapezius atrophy Vertebral ; prominent in serratus ant weakness/winging

8. FEEL T e n d er n e s s Swelling Palpable gap in muscles Acromioclavicular joint Coracoid process Subacromial bursa Biceps tendon

9. FEEL Muscle Pain Referral Patterns

10. MOVE Forward Flexion 0 – 160/180 Extension 0 – 45 External Rotation (Adduction) 0 – 60 Internal Rotation (Adduction) 0 – 70 Abduction 0 – 180 Adduction 0 – 20/40 External Rotation (Abduction) 0 – 90 External Rotation (Abduction) 0 – 70

11. MOVE Muscle Strength Test Pectoralis major Latissimus Dorsi Deltoid

12. MOVE T r a p e z i us S err a t u s Anterior R h o mb o i d s Muscle Strength Test

13. INSTABILITY Sulcus sign Anterior and posterior draw Anterior apprehension test Relocation test

14. SULCUS TEST Detect inferior instability of the gleno -humeral joint “+” if dimpling of the skin below the acromion or widening of the subacromial space on palpation; >2cm translation

15. Anterior and Posterior Drawer Detect anterior and posterior instability of the gleno -humeral joint Observe any movement, clicks and patient apprehension. + if pain or apprehension by the client to assume this position for fear of shoulder dislocation

16. APPREHENSION TEST Detect instability of the gleno -humeral joint Shoulder abducted to 90°, Slight stress to humeral head directed in anterior direction while externally rotating shoulder + if pain or apprehension by the client to assume this position for fear of shoulder dislocation

17. RELOCATION TEST Detect Anterior instability After a positive apprehension Apply posteriorly directed force over externally rotated humeral head Positive test is relief of apprehension

18. IMPINGEMENT Neer’s Test Hawkin’s Test Jobes Test

19. NEER’S TEST Test for impingement Passively take UE into full shoulder flexion with humerus in Internal Rotation “+” if Pain located to the subacromial space or anterior edge of acromion pain may be indicative of impingement of the supraspinatus or long head of the biceps

20. HAWKINS/KENNEDY TEST Test for impingement place shoulder in 90° of flexion, slight horizontal adduction, & maximal IR “+” if Pain located to the subacromial space or anterior edge of acromion + test = shoulder pain due to impingement of supraspinatus between greater tuberosity against coracoacromial arch

21. JOBES TEST Test supraspinatus muscle Elevate Upper Extrimity 30°–45° in plane of the scapula with Internal Rotation, resist elevation + test = reproduction of pain &/or weakness

22. ROTATOR CUFF External rotation lag sign (ERLS) Hornblowers sign Internal rotation lag sign (IRLS) Belly Press Test Bear Hug Test

23. External Rotation Lag Sign (ERLS) Test for infraspinatus tear. The clinician grasps the patient’s wrist and then places the elbow at 90 degrees of flexion and the shoulder at 20 degrees of elevation in the scapular plane. Passively externally rotates the shoulder and, at the end range, asks the patient to maintain this position as the patient’s wrist is released A positive test, which is indicated by lag that occurs with the inability of the patient to maintain his or her arm near full External Rotation

24. HORNBLOWERS SIGN Test teres minor muscle Shoulder in 90° abd & elbow flexed so that the hand comes to the mouth (blowing a horn) + test = reproduction of pain &/or inability to maintain Upper Extrimity in External Rotation

25. Internal Rotation Lag Sign (IRLS) Test for Subscapularis tear clinician grasps the patient’s shoulder with one hand and the wrist with the other and then lifts the patient’s arm off the back. The clinician then asks the patient to maintain this position as the wrist is released. A positive test, which is manifested with an inability of the patient to maintain his or her arm off of the back

26. BELLY PRESS TEST Test subscapularis muscle Press the hand into belly A positive test, which results in the elbow dropping behind the body into extension, indicates a subscapularis tear

27. BEAR HUG TEST Test subscapularis tear The patient place the hand of the involved arm on the contralateral acromioclavicular joint with the hand flat and fingers extended. The elbow of the involved arm should be positioned anterior to the body at the same height as the shoulders. The patient is asked to maintain that position while the examiner applies an ER force to the forear A positive test is w eakness or inability to maintain that position

28. BISCEPS Speed’s test Yergason’s test

29. SPEED’S TEST Assess for biceps tendonitis or labrum problem Resist elevation + test = pain with biceps tendonitis & sense of instability with labral px

30. YERGASON’S TEST Assess for Bisceps Tendon The patient sits or stands, and the upper arm is positioned with the elbow at 90 degrees of flexion and the forearm pronated. The patient is asked to supinate his or her forearm against the manual resistance of the clinician. + test = pain over the bicipital groove

31. SLAP (Superior Labrum Anterior to Posterior) Lession O’Briens Test Pain Provocation test Crank Test Jerk Test Kim Test

32. O’BRIENS TEST Assess Assess for labrum or AC joint problem Resist elevation in Internal Rotation then repeat in External Rotation + test = pain in IR > ER; pain “inside” shoulder is labrum & pain “on top” of shoulder is AC

33. PAIN PROVOCATION TEST Assess Assess for labrum Traction the biceps by passively taking the forearm into maximal pronation + test = biceps will tug on labrum & reproduces the pain in the superior region of the joint line (superior labrum )

34. CRANK TEST Assess Assess for labrum Their arm is elevated to 160 degrees in the scapular plane of the body and is positioned in maximal internal or ER. The clinician then applies an axial load along the humerus . A positive test is indicated by the reproduction of a painful click in the shoulder during the maneuver.

35. JERK TEST Detect a posteroinferior labral lesion The clinician grasps the patient’s elbow with one hand and the scapula with the other, and then positions the patient’s arm at 90 degrees of abduction and IR. The clinician then provides an axial compression-based load to the humerus through the elbow while maintaining the horizontally abducted arm. A positive test is indicated by sharp shoulder pain with or without a clunk or click

36. KIM TEST Detect a posteroinferior labral lesion The clinician grasps the elbow with one hand and the midhumeral region with the other hand, and then elevates the patient’s arm to 90 degrees of abduction. Simultaneously, the clinician provides an axial load to the humerus and a 45-degree diagonal elevation to the distal humerus concurrent with a posteroinferior glide to the proximal humerus . A positive test is indicated by a sudden onset of posterior shoulder pain.

37. AC JOINT Ac Shear Test Coracoclavicular Ligament Test Cross-body Adduction Test

38. AC SHEAR TEST Assess for AC sprain Clinician interlaces fingers & surrounds the AC joint; squeezing the hands together compresses the AC joint + test = pain or excessive move is indicative of damage to the AC ligaments

39. CORACOCLAVICULAR LIGAMENT TEST Assess CC ligament Place affected Upper Extrimity behind back, palpate CC ligament while stabilizing clavicle; pulling inferior angle of scapula away from ribs to stress the conoid portion; pulling medial border of scapula away from the ribs stresses the trapezoid portion + test = pain

40. CROSS-BODY ADDUCTION Assess AC ligament Shoulder flexed to 90°, horizontally + test = pain @ AC joint

41. Shoulder SURGICAL APPROACH

42. The anterior surgical approach offers good wide exposure of the shoulder joint, allowing repairs to be made of its anterior, inferior, and superior coverings. anterior approach permits the following : Reconstruction of recurrent dislocations Drainage of sepsis Biopsy and excision of tumors Repair or stabilization of the tendon of the long head of the biceps Shoulder arthroplasties, which usually are inserted through modified anterior incisions Fixation of fractures of the proximal humerus Anterior Approach

43. Positioning sandbag Reduce venous pressure  decrease bleeding Allow the blood to drain away from the operative field during surgery

44. LANDMARKS AND INCISION Two Skin Incision: Anterior Incision Axillary Incision Anterior Incision AxiIlary incision Retract the axillary incision cephalad to expose the cephalic vein and the deltopectoral groove.

45. Superficial Surgical Dissection Find the deltopectoral groove, with its cephalic vein. Retract the pectoralis major medially and the deltoid laterally, splitting the two muscles apart

46. DEEP DISECTION

47. DEEP DISECTION

48. DANGER Nerves musculocutaneous nerve Enters the body of the coracobrachialis to the muscle's origin at the coracoid process . nerve enters the muscle from its medial side, all dissection must remain on the lateral side Do not to retract the muscle inferiorly, to avoid stretching the nerve and causing paralysis of the elbow flexors Vessel cephalic vein The cephalic vein should be preserved traumatized cephalic vein should be ligated to prevent the slight danger of thromboembolism

49. Lateral Approach The lateral approach provides limited access to the head and surgical neck of the humerus . The uses of the lateral approach include the following: Open reduction and internal fixation of displaced fractures of the greater tuberosity of the humerus Open reduction and internal fixation of humeral neck fractures Removal of calcific deposits from the subacromial bursa Repair of the supraspinatus tendon Repair of the rotator cuff

50. POSITIONING Position of the patient on the operating table for the lateral approach to the shoulder. Elevate the table 45°. Place a sandbag under the shoulder to lift it off the operating table SANDBAG

51. LANDMARK AND INCISION LANDMARK The acromion is rectangular. Its bony dorsum and lateral border are easy to palpate on the outer aspect of the shoulder. INCISION Make a 5-cm longitudinal incision from the tip of the acromion down the lateral aspect of the arm

52. Superficial Surgical Dissection Split the deltoid muscle in the line of its fibers from the acromion downward for 5 cm. Insert a suture at the inferior apex of the split to help prevent it from extending accidentally, with consequent axillary nerve damage, as the exposure is worked on

53. Deep Surgical Dissection

54. DANGER Nerves The axillary nerve leaves the posterior wall of the axilla by penetrating the quadrangular space. Then it winds around the humerus with the posterior circumflex humeral arteries

55. Posterior Approach The posterior approach offers access to the posterior and inferior aspects of the shoulder joinIt rarely is needed, but can be used in the following instances : Repairs in cases of recurrent posterior dislocation or subluxation of the shoulder Glenoid osteotomy Biopsy and excision of tumors Removal of loose bodies in the posterior recess of the shoulder Drainage of sepsis (the approach allows dependent drainage with the patient in the normal position in bed) Treatment of fractures of the scapula neck, particularly those in association with fractured clavicles (floating shoulder) Treatment of posterior fracture dislocations of the proximal humerus

56. POSITIONING Place the patient in a lateral position on the edge of the operating table with the affected side uppermost. Drape him or her to allow independent movement of the arm. Stand behind the patient and take care that the ear is not folded accidentally under the head

57. LANDMARK AND INCISION Landmarks The acromion and the spine of the scapula form one continuous arch. The spine of the scapula extends obliquely across the upper four fifths of the dorsum of the scapula and ends in a flat, smooth triangle at the medial border of the scapula. It is easy to palpate. Incision Make a linear incision along the entire length of the scapular spine, extending to the posterior corner of the acromion

58. DANGER Nerves The axillary nerve runs through the quadrangular space beneath the teres minor. The suprascapular nerve passes around the base of the spine of the scapula as it runs from the supraspinous fossa to the infraspinous fossa. Vessel The posterior circumflex humeral artery runs with the axillary nerve in the quadrangular space beneath the inferior border of the teres minor muscle. Damage to this artery leads to hemorrhaging that is difficult to control. This danger can be avoided by staying in the correct intermuscular plane

59. ( Syukron Jazakalloh Khoir ) HATUR NUHUN